248.indd PRACTICAL NEUROLOGY366 © 2004 Blackwell Publishing Ltd ART AND NEUROLOGY How ne disease artist’s w Figure 1 Giorgio de Chirico. Lithograph from Calligrammes. (1930) © DACS 2004 o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/ DECEMBER 2004 367 © 2004 Blackwell Publishing Ltd INTRODUCTION A great deal has been written about the relation- ship between art and disease. Apart from the de- piction of diseases in works of art, a subject often generating considerable debate, there is also the problem of how disease can infl uence what an artist paints, and particularly how it is painted. This has been much researched with regard to psychiatric conditions (MacGregor 1989; Jami- son 1993) and eye disease (Trevor-Roper 1988), as well as to various disabling conditions (Sand- blom 1992; Emery 1997). Here, however, I will focus on some neurological conditions that have affl icted various artists and how these af- fected their work. MIGRAINE Several artists have suffered with migraine includ- ing the British artists Sarah Raphael (1960–2001) and J.J. Ignatius Brennan (b. 1949). But the best known example is the Italian surrealist painter Georgio de Chirico (1888–1978) (Fuller & Gale 1988). All three artists depicted the zigzag motifs characteristic of fortifi cation spectra and this is well illustrated for example in Chirico’s litho- graph from Calligrammes of 1930 (Fig. 1). INTRACRANIAL TUMOURS Percy Wyndham Lewis (1884–1957), an English Alan E. H. Emery Green College, Oxford, UK OX2 6HG Practical Neurology, 2004, 4, 366–371 eurological e can affect an work artist who founded vorticism (a variety of cu- bism) in the early part of the last century, de- veloped a pituitary tumour that he refused to have removed and which eventually resulted in blindness and ultimately his death (Farrington 1980). Early in the course of the disease when he could still see, but with some diffi culty, he had to hold his face close up to the canvas when paint- ing. He nevertheless produced at the time a very fi ne portrait of T. S. Eliot (Fig. 2). MULTIPLE SCLEROSIS Although a relatively common disorder, there appears to be only one well-documented case of the disease in a professional artist. This was Peter MacKarell, an English artist who suffered from the disease during the last 8 years of his life and who died in 1988. How it affected his art is graphically illustrated in his book (MacKarell 1990). At fi rst his left hand became paralysed so he trained himself to paint with his right hand. Particularly revealing is a series of paintings de- picting the development and later recovery of a right central scotoma (Fig. 3). MOTOR NEURON DISEASE Once motor neuron disease (MND) has pro- gressed it would generally be very diffi cult for an artist to continue to paint. But some have, and o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/ PRACTICAL NEUROLOGY368 © 2004 Blackwell Publishing Ltd a good example is John Paterson, a Scottish art- ist who graduated from the Glasgow School of Art in 1983. In 1996 he was diagnosed as having a combination of MND and an apparently as- sociated chronic infl ammatory demyelinating polyneuropathy. His earlier paintings refl ected his love of the countryside. However as the dis- ease progressed his work became particularly revealing in his personal relationships (Fig. 4) and there is an understandable neglect of detail. With his family he founded the Dochas Fund (‘dochas’ is Gaelic for hope), a charity to raise funds for research into MND and related disor- ders. He died in 1998. PARKINSONISM Salvador Dali (1904–89) was certainly eccentric in his behaviour (Critchley 1992) and also suf- fered from mild depression throughout most of his life. However in later years he also devel- oped parkinsonism like his father before him. It is very diffi cult to assess how this might have been refl ected in his later work. To the casual Figure 2 Percy Wyndham Lewis. Portrait of T. S. Eliot. ©Wyndham Lewis and the estate of the late Mrs G A Wyndham Lewis by kind permission of the Wyndham Lewis Memorial Trust (a registered charity). Figure 3 Peter MacKarell. Self portrait – recovering from a right central scotoma. Reproduced from Depictions of an Odyssey (1990) Corsham, UK: National Society for Education in Art & Design (NSEAD), 1990, with permission. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/ DECEMBER 2004 369 © 2004 Blackwell Publishing Ltd observer, he continued to depict rather uncon- ventional themes throughout his life. A severe tremor would of course have precluded any seri- ous artistic endeavours. CEREBROVASCULAR DISEASE A hemiplegia resulting from a stroke might cause a painter to learn to paint with his other hand. The result, if unacceptable to the artist, might well generate considerable frustration. Such frustration and anger is well illustrated in The Blinded Samson (1912) painted by the Ger- man artist Lovis Corinth (1858–1925) when he was slowly recovering from a stroke (Fig. 5). However, the results of a stroke are some- times more revealingly displayed in how an art- ist depicts subjects. This is well illustrated in the phenomenon of ‘hemineglect’, where there is de- fective representation of subjects on one side of a painting with subjects on the other side being normally represented (Vigouroux et al. 1990). Hemineglect occurs in around 80% of patients with acute right hemisphere strokes (the right pa- Figure 4 John Paterson. Space in Between Reproduced by kind permission of The Dochas Fund. Figure 5 Lovis Corinth. The Blinded Samson (1912). Reproduced by kind permission of the Staatliche Museen, Berlin. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/ PRACTICAL NEUROLOGY370 © 2004 Blackwell Publishing Ltd centred on how disease affected perception and image representation. But as Anthony Storr has argued, in severe mental illness creativity, rather than being enhanced in some way, is often sig- nifi cantly impaired (Storr 1989). In recent years there have also been several reports of the effects of various dementias on the work of artists. Mervyn Peake (1911–68), a brilliant English artist and writer, suffered from a chronic neurodegenerative disease, probably dementia with Lewy bodies (Sahlas 2003). His illness began in his forties and he was confi ned to hospital for the last 4 years of his life. His cog- nitive decline was associated with a tremor and with visual hallucinations that he portrayed in several sketches and which often depicted ex- pressions of fear and apprehension. Though he was investigated at various centres, including the National Hospital, Queen Square, London, no defi nitive diagnosis was ever made. At the time there were no imaging techniques avail- able, nor any brain pathology. More recently the Dutch–American ab- stract expressionist painter Willem de Kooning (1904–97) developed a dementia in his sixties but continued to paint throughout the rest of his life (Espinel 1996). As the disease advanced his art became progressively more abstract and diffi cult to understand yet continued to attract the attention of critics. Interestingly another recent professional art- ist, but whose premorbid work was more con- ventional, developed frontotemporal dementia rietal areas being particularly involved in space perception) with failure to represent objects on the left side (Halligan & Marshall 1997). It can occur in those without visual fi eld defects. Several artists have suffered right hemisphere strokes with subsequent hemineglect of varying degrees and duration including Lovis Corinth (1858–1925), Otto Dix (1891–1969) and Anton Räderscheidt (1892–1970). As recovery from a stroke occurs so may impairment due to hemineglect (Fig. 6). A related condition is simultanagnosia: the patient appears to pay attention to only part of an image with an inability to perceive the en- tire visual scene. It results from unilateral or bi- lateral damage to the posterior parietal cortex. The phenomenon has been described in several patients including recently a professional art- ist who suffered from a basilar artery embolic stroke (Smith et al. 2003). Prior to the stroke she painted scenes entirely from memory. But following her stroke her paintings revealed se- lective attention only to certain areas with an in- ability to perceive the overall meaning of a fi gure or scene. Detailed studies, including imaging, of artists with this condition could be very instruc- tive in helping our understanding of how we in- terpret visual memories. DEMENTIA Much has been written about the effects on ar- tistic endeavours of psychiatric illnesses as well as drugs and alcohol (for example Critchley 1987; Post 1994). Most of these studies have Figure 6 Left hemineglect after stroke. Vigouroux et al. 1990. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/ DECEMBER 2004 371 © 2004 Blackwell Publishing Ltd (Mell et al. 2003). As the disease progressed language and executive skills declined but her paintings became freer and more original sug- gesting that language is not required for certain types of visual creativity. Finally, the progressive effect of Alzheimer’s disease on the work of a contemporary art- ist, William Utermohlen, has been graphically displayed. He was diagnosed with the disease in 1996 and created a number of self-portraits over the last few years (Crutch et al. 2001). These demonstrate very clearly the changes in his self perception (Fig. 7). Because of the progressive nature of demen- tia, the neurologist has an opportunity to study how the disease affects an artist’s work over time and to correlate such changes with the results of neuroimaging. In this way it affords a unique way of studying how detailed changes in perception can be linked to localized cerebral functions. CONCLUSIONS Apart from psychiatric illnesses, which have been much studied in the past, a number of artists have been affl icted by certain neurological disorders including migraine, intracranial tumours, multi- ple sclerosis, motor neuron disease, parkinsonism, cerebrovascular disease, and various dementias. All of these conditions have, in various ways, af- fected their work. In the case of the dementias, correlating such changes over time with the re- sults of neuroimaging could help throw more light on our understanding of the relationships between cognitive and visual pathways. REFERENCES Critchley EMR (1987) Hallucinations and Their Impact on Art. Carnegie Press, Preston. Critchley EMR (1992) Art and reality. Journal of the His- tory of the Neurosciences, 1, 243–67. Crutch SJ, Isaacs R & Rossor MN (2001) Some workmen can blame their tools: artistic change in an individual with Alzheimer’s disease. Lancet, 357, 2129–33. Emery AEH (1997) Medicine, artists and their art. Jour- nal of the Royal College of Physicians, 31, 450–5. Espinel CH (1996) De Kooning’s late colours and forms: dementia, creativity and the healing power of art. Lan- cet, 347, 1096–8. Farrington J (1980) Wyndham Lewis. Lund Humphries, London. Fuller GN & Gale MV (1988) Migraine aura as artistic inspiration. British Medical Journal, 297, 1670–2. Halligan PW & Marshall JC (1997) The art of visual ne- glect. Lancet, 350, 139–40. Jamison KR (1993) Touched with Fire. Macmillan, New York. MacGregor JM (1989) The Discovery of the Art of the Insane. Princeton University Press, Princeton. MacKarell P (1990) Depictions of an Odyssey. National. Society for Education in Art and Design (NSEAD), Corsham, UK. Mell JC, Howard SM & Miller BL (2003) Art and the brain: the infl uence of frontotemporal dementia on an accomplished artist. Neurology, 60, 1707–10. Post F (1994) Creativity and psychopathology: a study of 291 world famous men. British Journal of Psychiatry, 165, 22–34. Sahlas DJ (2003) Dementia with Lewy bodies and the neurobehavioral decline of Mervyn Peake. Archives of Neurology, 60, 889–92. Sandblom P (1992) Creativity and Disease. Marion Bo- yars, New York, London. Smith WS, Mindelzun RE & Miller B (2003) Simultan- agnosia through the eyes of an artist. Neurology, 60, 1832–4. Storr A (1989). Churchill’s Black Dog and other Phe- nomena of the Human Mind. Collins, London. Trevor-Roper P (1988) The World Through Blunted Sight. Allen Lane. Penguin Press, London. Vigouroux RA, Bonnefoi B & Khalil R (1990) [Réalisa- tions picturales chez un artiste peintre présentant une héminégligence gauche.] Revue Neurological (Paris), 146, 665–70. Figure 7 William Utermohlen. Series of Self-portraits. Painted at age 60 (A), 62 (B), 63 (C), 64 (D), pencil drawing at 66 (E), and abstract self-portrait at 65 (F). In Crutch et al. 2001, reproduced by kind permission of the Lancet. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://p n .b m j.co m / P ra ct N e u ro l: first p u b lish e d a s 1 0 .1 1 1 1 /j.1 4 7 4 -7 7 6 6 .2 0 0 4 .0 0 2 4 8 .x o n 1 D e ce m b e r 2 0 0 4 . D o w n lo a d e d fro m http://pn.bmj.com/